Water Fluoridation in South Africa

May 1997

Table of Contents

Government White Paper proposing Water Fluoridation
Democratic Party Media Statement
Fluoridation in South Africa
Write to the Minister of Health
Sample letter to Minister Dr. Zuma

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South African Government Gazette, 16 April 1997

Notice 667 of 1997

Department of Health

White Paper for the Transformation of the Health System in South Africa

. . . . .

13.2. The incidence of common oral diseases should be reduced by the promotion of health, prevention of oral diseases and provision of basic curative and rehabilitative oral health service.

13.2.1 Minimum package of oral health care

a) A defined minimum package of oral health care should be provided to the priority groups listed above. this package should consist of an annual examination, bitweing radiographs, cleaning of teeth, simple 1- 3 surface fillings, fissure sealants and emergency relief of pain and infection control.

b) Systemic water fluoridation

(i) Systemic water fluoridation should be implemented immediately, at least in the major metropolitan areas of South Africa, the remaining areas being phased in systematically.

(ii) Alternative methods of fluoridation, such as the use of fluoride toothpaste and fluoride mouth-rinses, should be introduced in schools and among priority groups

(iii) Legislation to enable the fluoridation of milk and salt should be pursued

(iv) Dietary supplements (fluorides and vitamins) should be included as part of the Integrated Nutrition Programme

. . . . .

Media Statement

Democratic Party, Box 1476 Cape Town 8000

Tel. (021) 45 1431 Fax (021) 461 5278 (?)

Re: White Paper on Health Transformation

The Minister of Health, in her inimitably arrogant way, has surprised Parliament and the Portfolio Committee on Health by producing a White Paper when no-one else even knew it was in the pipeline. It is strange that the white Paper was published first in the Government Gazette and not formally tabled, although Parliament is in session. Dr. Zuma has chosen to issue it when her budget vote is just a week away and the question must be asked: is it an attempt to deflect attention away from her budget and further embarrassing questions on her department's unauthorized over-expenditure?

A few preliminary comments can be made on the White Paper itself:

Firstly, why was it not preceded by a Green Paper? The Minister has had nine or more committees looking at various aspects of health care policy, but this is the first time any form of definitive document covering all aspects has been produced. The process demands that interested and affected groups and individuals have the opportunity to comment.

Secondly, the White Paper states that social health insurance will be introduced. This raises many and varied questions, not least who will pay for it and who will benefit from it. The implication is that all South Africans, whether they are members of Medical Aid schemes or not, will have to contribute. How will this insurance be collected? Will it be a dedicated tax - something the department has been interested in for a long time - or will it be collected along the same lines as Workmen's Compensation? How will such an insurance scheme affect the existing medical aid schemes? The curtness of the paragraph on this matter leaves many unanswered questions and has serious implication for all South Africans.

Thirdly, it is essential for the successful delivery of health care that any policy allows for and encourages close co-operation between the public and private health care sectors. While the Minister in her preface refers to the "pooling of both our public and private resources" it is not clear whether this White Paper allows for co-operation in the true sense - a working together of two systems - or whether in fact a system is being introduced to gradually weaken the private health care sector by over-regulation and grater interference.

Lastly, we welcome the whit Paper's proposals to improve the delivery of health care to all South Africans and endorse its greater commitment to primary health care.

Mike Ellis (021) 405 3507 Cell 083 300 6470

Fluoridation in South Africa

Fluoride is an example of an basic element which may be beneficial at low concentrations, but which has a narrow margin of safety, and is detrimental to health at higher concentrations. This applies not only to human beings but also to animals and aquatic creatures. The beneficial concentration for humans is 0.7 to 1 milligram per liter and 0 to 2 mg/l for animals.

Detrimental levels fro humans start at 1.5 mg/l with tooth staining. Damage to teeth and skeleton occurs at around 3 mg/l according to the World Health Organisation. At levels exceeding 3 mg/l serious skeletal damage may occur. Continuous use of fluoride above 8 mg/l usually leads to loss of teeth as well as crippling due to vertebral damage. Death from acute fluoride poisoning may occur if concentration exceed 100 mg/l.

The aquatic ecosystems are even more sensitive. The target water quality value for fluoride for aquatic life protection is 0.75 mg/l, and the chronic exposure value (where chronic toxicity to aquatic life appears) is 1.5 mg/l. Excess fluoride once added to a water supply is both difficult and expensive to remove.

As South Africa is a water scarce country, one of the basic principles of the Water Act (Act 54 of 1956) is that water after use must be returned to the river from which it was abstracted. Following this principle, repeated cycles of abstraction and return of used water to the river systems are of widespread occurrence and indeed a necessity in this country, this is particularly so in the interior of the country. In order to keep the returned water fit for use it is imperative that additions of soluble pollutants are kept to a minimum, as the dissolved salts progressively increase in concentration with each use cycle. This type of excessive concentration has already occurred with sulfate as a consequence of its presence in mining output.

The practice of the addition of fluoride to the optimum concentration of 1 mg/l is based on the assumption that the water only goes through once cycle of use and is not reused repeatedly.

If fluoridation were to be practised on a large scale in the interior of the country, this might mean that fluoride removal technologies would have to be installed by downstream users.

Fluoride dosing control and particularly accurate analysis of fluoride concentrations is not a simple exercise which implies that it would be extremely difficult for smaller water supply facilities to control accurately the level of fluoride dosed. Because of the small margin of safety between beneficial and toxic levels of fluoride, the consequence of accidental overdosing will be extremely serious.

A particularly dangerous aspect of fluoridation is that fluoride does not impart any taste or smell to the water. Thus the consumer is unable to protect himself in the event of accidental over-fluoridation of water. By contrast, over chlorination is very obvious to the consumer through the strong taste and odour of the chlorine.

The strict control and monitoring that is needed to implement fluoridation implies that many small municipalities will find it difficult to safely do this. Even more difficult will be the implementation of fluoridation technology to safeguard aquatic ecosystems, not to mention man. Safe fluoridation and inevitable fluoridation will only be possible in the case of large well managed water boards.

By contrast, chlorine used for water disinfection, has a very wide margin between harmless concentrations and toxic concentrations. The consequences of slight overdosing with chlorine are not nearly so serious as in the case with fluoride. Yet despite the large safety margin of chlorine dosing, fish deaths due to chlorine overdosing have already occurred in this country.

Water actually used for drinking purposes only constitutes a small fraction of the water used for domestic purposes. The major portion being used for watering gardens and washing purposes. This has two implications: Firstly that fluoridation of domestic water is a wasteful method of ensuring optimum fluoridation levels. Secondly, that long term detrimental effects may occur due to build up of fluoride levels in irrigated soils.

It is worth noting that water of some areas have already naturally a fluoride level of about half of 0.75 mg/l. Further, the naturally occurring fluoride is 'Calcium fluoride', whereas the fluoride additive is 'Sodium fluoride' which is rated as highly poisonous.

Write to the Minister of Health

Minister Dr. Nkosazana C Dlamini-Zuma
Private Bag X399, Pretoria 0001
Street: Union Buildings, East Wing, Room 949, Pretoria 0002
Civitas Building, Cnr Andries and Struben Streets, Pretoria 0002
Tel: (012) 328 4773/4 Fax: (012) 325 5526
Private Bag X9070, Cape Town 8000
Street: Room 413, 120 Plein Street, Cape Town 8001
Tel: (021) 45 7407/8 Fax: (021) 45 1575

Sample letter to Minister Dr. Zuma

Dear Minister Dr. Zuma

It is well known to you that fluoridation of drinking water causes more problems, dangers and environmental poisoning than it does good to man. Then why do you propose it in the White Paper Notice 667 of 1997?

I request that section 13.2.1 b) 'Systemic Water Fluoridation' and all subsections to be deleted.

Should you ignore my request and this section become law, I will do everything in my power to get a parliamentary investigation going into the relationship between your department and the aluminium producing industry and any other fluoride producers, including all channels of modern lobbying and overseas bank accounts.

It is in your and our countrie's interest to delete the above mentioned section from your White Paper!

Yours sincerely

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